What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should focus on warm soaks with antiseptic solution, topical antibiotics with steroids for inflammation, and surgical drainage if an abscess is present. 1

Diagnosis and Classification

Before initiating treatment, it's important to determine whether the paronychia is:

• Acute paronychia: Sudden onset, polymicrobial infections after nail barrier breach
• Chronic paronychia: Symptoms lasting at least six weeks, representing irritant dermatitis 2

Treatment Algorithm

For Acute Bacterial Paronychia:

1. First-line treatment:

   • Warm soaks with antiseptic solution (10-15 minutes, 2-3 times daily) 1
   • Consider 50:50 dilute vinegar soaks to nail folds twice daily as recommended by the American Academy of Dermatology 1

2. If inflammation persists:

   • Add topical antibiotics with steroids 1
   • Mid- to high-potency topical corticosteroid ointment for inflammation 1

3. If abscess is present:

   • Surgical drainage is mandatory 1, 2
   • Drainage techniques range from using a hypodermic needle to wide incision with a scalpel 2
   • The DAREJD technique (lifting the nail fold with the tip of a 21G or 23G needle) can be effective and doesn't require anesthesia 3

4. Oral antibiotics:

   • Usually not needed if adequate drainage is achieved
   • Consider for immunocompromised patients or severe infections 2
   • Lower threshold for antibiotic therapy if infection is suspected (per Infectious Diseases Society of America) 1

For Chronic Paronychia:

1. Eliminate causative factors:

   • Identify and avoid irritants (acids, alkalis, chemicals) 2
   • Keep hands/feet dry and avoid prolonged water exposure 1
   • Wear gloves during wet work 1

2. Topical treatments:

   • High-potency topical corticosteroids alone or combined with topical antibiotics 1
   • Calcineurin inhibitors can be considered 2
   • Apply daily topical emollients to cuticles and periungual tissues 1

3. For fungal involvement:

   • Topical antifungals (imidazoles) 1
   • Oral fluconazole for Candida species 1
   • Itraconazole for resistant cases 1

4. Surgical options for recalcitrant cases:

   • En bloc excision of the proximal nail fold
   • Eponychial marsupialization (with or without nail plate removal) 4

Special Considerations

Diabetic Patients

• Require more vigilant monitoring and earlier intervention due to increased infection risk 1
• Keep the area dry to prevent further infection 1

Immunocompromised Patients

• Lower threshold for oral antibiotics and more aggressive treatment 1
• More frequent follow-up recommended

Follow-up and Monitoring

• Regular follow-up every 2-4 weeks until resolution 1
• Return immediately if signs of infection develop 1
• For cases requiring drainage, follow-up within 1-2 weeks to ensure proper healing 1

Prevention

• Proper nail care: trim nails straight across, file nail surfaces after softening 1
• Keep nails short and clean 1
• Wear shoes with adequate toe box width 1
• Avoid high heels and pointed shoes 1
• Apply daily topical emollients to cuticles 1

Common Pitfalls to Avoid

1. Delayed drainage of abscesses can lead to severe deformities of the fingers 3
2. Overlooking chronic paronychia as a form of contact dermatitis rather than an infection 5
3. Failure to investigate unusual cases of chronic paronychia that don't respond to standard treatment (could indicate malignancy) 5
4. Neglecting patient education which is paramount to reduce recurrence of both acute and chronic paronychia 2

By following this structured approach to paronychia treatment, focusing on the specific type and severity, clinicians can effectively manage this common condition while minimizing complications and recurrence.